Date: ____________________    Annual membership is from date of enrollment.

( ) New Member        ( ) Renewal

Please Print

Name _______________ Address _______________ City ____ State __ Zip _____

Home phone (__) ___________ Work phone (__) ___________ Fax (__) ___________ E-mail address ______________

Payment Method:
Payments to LHA are tax-deductible to the full extent of the law under section 501(c)(3) of the Internal Revenue Code.

( ) Check (payable to Lincoln Highway Association)

Credit card: ( ) Visa          ( ) MasterCard Credit card number: ____________________ Expiration Date: ___ / ___

Membership Categories:

( ) Student: $15 ( ) Individual:  $30 ( ) Family: $40

( ) Supporting: $50 ( ) Patron: $100 ( ) Life: $750  and up

( ) City or county government: $30 ( ) Non-profit organization: $30 ( ) Business: $50 ( ) Corporate: $100

State Affiliation

If you do not live in an LH state, please indicate preference for state affiliation. If more than one, $6.00 for each additional state.

[ ] NY [ ] IN [ ] UT

[ ] NJ [ ] IL [ ] NV

[ ] PA [ ] IA [ ] CA

[ ] WV [ ] NE

[ ] OH [ ] WY

Are you willing to serve on a committee?    ( ) Yes        ( ) No

If yes, check the committee(s) on which you would like to serve:

[ ] Archives [ ] Awards [ ] Bylaws

[ ] Conference [ ] Fund Raising [ ] Legislative

[ ] Markers [ ] Memberships [ ] Nominating

[ ] Public Relations [ ] Publications [ ] Preservation

[ ] Research

Copyright © 1999-2006 by the Lincoln Highway Association.